Telemedicine project improving health in rural Cambodia
Paul Heinzelman, MD MPH, Operation Village Health Project Leader,
Partners Telemedicine
Summary
 To leverage a growing Internet infrastructure
for health purposes within rural Cambodia, an email-based medical
consultation program called Operation Village Health was established in 2001 by Partners Telemedicine. Since
then, Harvard-affiliated physicians have been providing clinical
recommendations to Cambodian health workers caring for patients at a health
centre in Rovieng and a referral hospital in Ban Lung.
These consultations
are based on text and image-rich clinical documents composed by Cambodian
health workers, which are then emailed to physicians in Boston and in Phnom
Penh. Clinical recommendations are returned to the health workers within
hours of their receipt via email, allowing underserved villagers to receive
better care, and providing local clinicians the opportunity to strengthen
their knowledge. Since its inception, approximately 700
telemedicine-supported patient encounters have been completed. Operation
Village Health is the 2006 winner of the international Stockholm Challenge
in the category of Health.
Recent studies demonstrate a diminishing rate
of referral to facilities outside the village and a decrease in the duration
of chronic medical problems among villagers. A randomized survey of patients
demonstrated that they are satisfied with the telemedicine service and that
most are willing to pay an average of $0.63 per visit. Overall, this
initiative seeks to provide more effective and more affordable local care
for these underserved villagers, and serve as a sustainable model of
telemedicine-supported healthcare. The integration of new mobile technology
(digital pen) and the use of web-based clinical data storage are part of
future goals.
Introduction
Cambodia ranks among the lowest of countries
on the human development index and among the highest in terms of poverty.
Disparities in health care access are great – particularly in rural areas
where approximately 40% live below the poverty threshold and health worker
shortages prevail. The prevalence of infectious diseases and the growing
problem of chronic disease are forcing Cambodia to face a significant health
burden in the future. Since 1992, American Assistance for Cambodia has been
working to revitalize this country after the reign of the Khmer Rouge in the
late 1970s that resulted in the death of approximately two million people.
Through these efforts, a growing Internet infrastructure is accompanying the
broad construction of elementary schools throughout the rural countryside.
Project design and Implementation
Operation Village Health represents a health
application for a larger initiative known as Village Leap, a program
established by Japan Relief for Cambodia / American Assistance for Cambodia,
a non-governmental organization devoted to fostering development by bringing
technology to rural Cambodia. The mission of the organization is to
rehabilitate Cambodia in the aftermath of the Khmer Rouge reign and the
Vietnam War.
Village Leap has been responsible for
providing Internet access in nearly one third of the school facilities,
using solar and generator-powered satellite dishes, wireless technology and
mobile systems that receive and transmit data.
In the Ratanakiri province for example, the
network relies on an Internet access hub in the capital Banlung, wireless
solar-powered computers, and motorcycles equipped with a data storage
device, a wireless transmitter card, and an antenna. Each morning five
motorcycle couriers known as ‘motomen,’ download email in Banlung addressed
to villagers across the province. Travelling over rutted, red dirt roads they
deliver the mail using their wireless transmitters to connect with the
solar-powered computers in the small village schools. Simultaneously, the
transmitters upload the outgoing mail for transmission later in the day from
Banlung.
Using the connectivity and network built by
Village Leap, Operation Village Health has integrated technology into local
healthcare delivery by supporting village health workers, building local
capacity and providing care to people who otherwise would not have access to
medical expertise.
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Rural health centre |
To leverage this growing Internet infrastructure for
health purposes, an email-based telemedicine program was established in
2001. Through this program established by Partners Telemedicine,
Harvard-affiliated physicians provide clinical recommendations to Cambodian
health workers caring for patients at a health centre in the village of
Rovieng and a referral hospital in the town of Banlung. These consultations
rely on image-rich clinical documents composed by Cambodian physicians and
nurses that are emailed to physicians in Boston and in Phnom Penh for
review. These consultant physicians are specialists in a variety of fields
of medicine who voluntarily review the cases and return them to the health
workers within hours, allowing underserved villagers to receive improved
care while educating the local clinicians in appropriate medical practice.
Progress and Impact
Through telemedicine links, Operation Village Health
bridges the cultural and digital divide allowing healthcare to make its way
to rural Cambodia through a simple application of technology. Since 2001,
Operation Village Health telemedicine clinics have made substantial progress
in their intended mission of delivering high quality health care to local
villagers in the Rovieng village in the Preah Vihear province, (N Cambodia), and in the
town of Banlung in Ratanakiri province (NE Cambodia). Since its inception,
approximately 700 telemedicine-supported patient encounters have been
completed.
A retrospective case review studying the first 28
months of consultations documented significant transformation in local
health care access. When the telemedicine clinics began seeing patients, the
average duration of chief complaints at initial patient visits was 37
months, reflecting scarce access to health care in the area. By the end of
the second year of operation, average chief complaint duration decreased
from 37 months to 8 months, a significant reduction. Referrals to hospitals
outside of the village also decreased over the 28 month study period, due to
improvements in local health care worker’s skills and management techniques
as well as the development of enhanced clinic capabilities that made it
unnecessary for patients to travel to the distant hospital for certain basic
tests. Overall, the percent of transfers to facilities out of the village
dropped by 51% per year of clinical presence.
Importantly, a randomized survey of patients
revealed each was “very satisfied” or “satisfied” with the care they
received. None reported being “neither satisfied nor dissatisfied,”
“dissatisfied,” or “very dissatisfied.” Seventy-eight percent of the
patients reported they would be willing to pay for a visit at the clinic,
further indicating satisfaction with the care delivered.
In another retrospective case review currently
underway, data from the past one and a half years will be used to guide
further improvements in services provided to local villagers. The
feasibility of important public health initiatives such as preventive health
services and screening for prevalent diseases is also being investigated as
a critical future step.
New Technologies
A major obstacle to smooth exchange of
information between the US and Cambodia is the collection, transcription and
completeness of clinical data. A focus group of participating Operation
Village Health Cambodian physicians identified time-intensive keyboard
transcription for the creation of English language documents as a
significant interruption to the usual clinical workflow that required 50% of
the total time devoted to the telemedicine-supported encounters.
Additionally, feedback from US consulting specialists noted that incomplete
clinical documentation by local health workers was limiting their ability to
respond with definitive recommendations. These obstacles, amplified by
cultural and language differences, inhibit broader adoption among Cambodian
health workers and threaten the ultimate sustainability and scalability of
this otherwise successful program.
In response to these challenges, a number of
technologies and clinical tools were reviewed and assessed for applicability
to the Operation Village Health model. Digital pen technology, in
conjunction with pro-forma clinical templates, was proposed as a
cost-effective model with low cost of implementation and adoption, which
will be easily integrated into the workflow of the program. Advantages of
the digital pen technology solution include:
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Allows users to employ pen strokes to
normalize data and easily create structured documents in a non-native
language, eliminating the time-intensive keyboard transcription.
-
The digital pen looks and writes like a
standard ballpoint pen, and requires minimal training for proficient use
among providers across cultures and healthcare settings.
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Supports clinical documentation at the
point of care.
-
It is easily integrated into existing
workflows, and provides an ideal solution for capturing routine
encounter data and making data available in an electronic, structured
format.
-
Automatic capture and transfer of data and
information occurs, thus obviating or diminishing the need for keyboard
transcription.
-
Data is immediately available to
consulting physicians through a web-based portal.
Future directions
Through assessment of the existing program, we have
identified future targets for improving current operations and initiating
new clinical sites. Program improvements have already included the
introduction of a basic point-of-care laboratory and the development of
simple clinical guidelines for the ten most commonly encountered medical
problems, allowing local clinicians to manage their patients more
confidently and independently. Digitally-enhanced pen and paper clinical
forms are now being piloted for their potential to standardize the
locally-created clinical documents, and improve efficiency of this program.
In addition, direct integration of these clinical documents into an existing
Partners HealthCare web portal and database will allow more effective
tracking of the health status of these communities.
To date, this project has been financially
supported by donations made from corporations, foundations and individuals.
Future plans for this project rely on the donations from these sources.
Consulting physicians at Partners HealthCare provide their time on a
voluntary basis.
Overall, Operation Village Health seeks to
establish a platform for effective and affordable local care for underserved
villagers and emphasizes self-sufficiency. Over the next three years we aim
to validate its value by demonstrating that it is not only feasible, but
sustainable and scalable as well. Our belief is that this program may
ultimately serve as a model for cross-cultural telemedicine initiatives in
other remote settings of the developing world.
Link
Partners Telemedicine
http://telemedicine.partners.org/telemedicine/
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